PERMANENT EARLY DISMISSAL FORM

*THE EARLIEST ANY STUDENT CAN LEAVE THE BUILDING IS 11:30*



 DATE:  COUNSELOR:
 STUDENT NAME: GRADE:
 PARENT NAME:
 HOME PHONE:
 PARENT WORK PHONE:

 DAY of CYCLE and TIME of REQUESTED EARLY DISMISSAL:

 DAY

 TIME:

 1
 .

 2X
 .

 3
 .

 4
 .

 5
 .

 6
 .

 7
 .
 PARENT SIGNATURE:
 STUDENT SIGNATURE:
 COUNSELOR SIGNATURE:


STUDENTS MUST LEAVE THE BUILDING ON THE DAYS AND TIMES REQUESTED.
STUDENTS MUST CHECK OUT WITH CAMPUS SECURITY BEFORE LEAVING.